Abstract:Objectives: Recent studies have confirmed the contribution of the central nervous system (CNS) to the pathogenesis of Complex Regional Pain Syndrome (CRPS), because animal models of neuropathic pain syndromes demonstrate an overexpression of N-methyl-D-aspartate-receptors in the CNS. The aim of this work was to study the influence of a central acting drug-the N-methyl-D-aspartate receptor antagonist Memantine-in patients with CRPS of one upper extremity. Here we present the results of 6 patients treated with Memantine for 8 weeks.

Methods: All patients developed CRPS after traumatic injury to one upper extremity. To document changes during the study, levels of pain were measured after clenching the hand using a numeric pain intensity scale ranging from 0 (no pain) to 10 (maximum pain). Motor symptoms were documented for the fingers (fingertips to palm and fingernails to table) and the wrist (flexion/extension). Furthermore, the force was analyzed using a JAMAR-Dynamometer and a Pinchmeter. For assessment of central changes, functional magnetic resonance imaging and magnetoencephalography were used to further document the results of other experiments in 1 patient. Autonomic changes were photographed and pictures were compared before and after treatment with Memantine.

Results: Six months after treatment with Memantine, all patients showed a significant decrease in their levels of pain which coincided with an improvement in motor symptoms and autonomic changes. The functional magnetic resonance imaging and magnetoencephalography results provided evidence of cortical reorganization [changes in somatotopic maps in the primary somatosensory cortex (S1)]. These changes returned to a cortical pattern comparable to the unaffected side after treatment with Memantine.

Discussion: Based on these first results, the use of Memantine for treatment of CRPS seems promising and supports the hypothesis of a CNS contribution to the pathogenesis and maintenance of neuropathic pain syndromes.

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Sharp, burning, stinging, throbbing. Whatever you call it, it’s pain. We’ve all had it, and it all calls out for relief. Whether it’s migraine headache, arthritis, or low-back pain, there is generally an over-the-counter analgesic to take care of it, and, failing that, a prescription. But what happens when your pain simply won’t go away?

Nicolas Weider, D.O. (Doctor of Osteopathy), board-certified anesthesiologist and Physician-in-Charge at the Kaiser Permanente Panorama City Pain Management Clinic, explains that this is known as chronic pain, which comprises several different disorders.

“Chronic pain in general is pain that lasts more than three months,” said Weider. “there are many different types of pain disorders: for instance those due to congenital factors or to trauma. There are also specific pain disorders, like complex regional pain syndrome, when there is an activation of multiple parts of the nervous system.”

The ABC’s of Chronic Pain

More than 50 million Americans experience chronic pain, according to the American Pain Foundation, with back pain, headache and joint pain caused by arthritis being the most common conditions. Chronic pain costs the United States billions of dollars annually. According to Shahin Sadik, M.D., Board Certified in Anesthesiology, Pain Management and Pain Medicine, the U.S. is behind other major Western countries such as Canada, Great Britain, and the European Union in terms of palliative (pain-relieving) care. For a long time, pain per se received little attention or government funding, the situation is changing. Sadik, who has practices in Valencia and Palmdale, said part of the problem is the anti-drug message the government so assiduously dispenses.

“There is a stigma about opiate use,” said Sadik. “But prescribed and controlled, they are wonderful drugs. People are happier when their pain is down.”

Part of the stigma is among doctors themselves they are worried, said Sadik, that if their patients get addicted and want to stay on the medications longer than is necessary, they themselves will have trouble from the Drug Enforcement Agency, which oversees the dispensing of all controlled substances. But in his 14-year experience as a pain doctor, only approximately one to two percent of his patients have used their medications inappropriately.

“And these patients should be treated differently from street-drug addicts,” said Sadik. “Though they shouldn’t get narcotics anymore, we help them get into detoxification programs.”

Recognition

Congress designated the years 2001-2010 as the “Decade of Pain Control and Research.” Among the goals of this initiative are the requirement that U.S. hospitals and nursing homes meet new standards of pain management, and that health-care professionals be more informed about the nature of chronic pain.

Physicians have learned that pain is much more complicated than had been previously thought, said Weider, involving many different mechanisms depending on the source of the underlying problem. In some cases, pain receptors begin to act on their own, with concomitant physical changes in the behavior of the nerves, making chronic pain very difficult to treat.

Sadik decided on pain management as a sub-specialty because he himself was a chronic pain patient, due to an automobile injury.

A Stuck Switch

Simple pain involves the transfer of basic information from the site of the injury to the brain. For instance when you get a sunburn, the initial injury is at the level of the skin, whose nerves send a signal to the spinal cord and from there to the brain. With chronic pain, however, there is an over-sensitization of the nerves so that they feel pain all the time. “In fact, the nerves create their own circuit that persists, even when there is no longer an ‘original’ injury,” said Weider. “This is caused by chemicals shuttled on the spinal cord, which effectively reset the suffering person’s pain ‘thermostat.’ The goal of treatment for chronic pain is to try to set that thermostat back.'”

This is how antidepressants and anti-seizure medications can alleviate chronic pain, said Sadik. They work directly on the nerves to stop them from “firing,” which is what causes the pain.

Treatment of chronic pain differs from most other medical techniques in that practitioners might essentially “throw the book” at the pain, whereas in general medical approaches are more fine-tuned mechanisms. Because the theory is that pain-inducing chemical signals are “wound up,” and the practitioner wants to break that cycle, he or she will often use whatever works, whether that involves neurochemical stimulation, medication, removal of disks for back pain, or exercise, for instance if the issue is that the patient lacks core strength.

“Or we might use all of them,” said Weider. “The traditional thinking in medicine is to try things systematically, whereas for chronic pain we might try remedies in parallel to see what works.”

What has changed in the past decade or so, is that pain is now being taken seriously as a chronic disease, said Weider, like diabetes, or any other chronic condition. The key insight is to see all pain as urgent, whether it is acute or chronic.

The Emotional Connection

It has long been understood by traditional cultures and by the psychotherapeutic community that emotions have a relation to pain. This is not the same thing as saying to sufferers of chronic pain that “it’s all in their head” – on the contrary, neurology is helping to explain the specific pathways whereby emotions exacerbate or mitigate pain.

“Your mind does not create the pain,” said Weider, “but it can create a tendency to focus on it.”

For instance, many pain patients find that their pain increases at night. Weider said that this is sometimes due to the fact that there are fewer distractions at night, and actually presents a therapeutic opportunity to use techniques like guided imagery to take their mind off their pain. This is especially helpful since using imagery is a skill that patients can develop on their own, and since part of the experience of pain is feeling out of control, the sense of control itself can alleviate some of the pain. In addition, there is abundant evidence, said Sadik, that chronic pain can cause other symptoms, like depression.

“Pain is both emotional and sensory,” he said. “Depressed people often have a lower pain threshold, which sets them up for more pain. It’s a vicious cycle and when we address the emotional component of dealing with chronic pain, the patient’s demeanor improves; they don’t feel so hopeless, whereas before they couldn’t see a future out of tunnel of pain. That’s part of our job too.”

Pain researchers are confident that future studies will further illuminate the relationship between emotions and chronic pain.

An Eclectic Approach

Because chronic pain has many causes, practitioners avail themselves of many remedies. These can be medications, like anti-inflammatories, anti-seizure medications, muscle relaxants and opiates like codeine, methadone and morphine. Other, non-pharmaceutical modalities like heat, chiropractic and massage are also used.

“We figure out what works, and whatever it is, we use that,” said Weider. Non-medicinal modalities are especially helpful for elderly patients, since they can be particularly bothered by the side-effects of muscle relaxants and pain medications, which can promote loss of balance and falls. This sets up a situation where the elderly become afraid to move, and their resulting inactivity, or even fear of movement itself, can make their pain worse. Though the kinds of conditions Weider and Sadik may see, e.g.: low back pain, muscle pain and arthritis, are common, the difference is in how they approach the problem and the patient.

“We see (patients) after they have been evaluated by a primary doctor or even by a specialist, when the outcome has not been satisfactory,” said Weider. “And they ask us to help them. It can be the most frustrating thing to handle, to have a pain that won’t go away but which doesn’t have a specific cause.”

Whether there is an objectively obvious cause, or whether the pain is subjectively perceived doesn’t matter, said Weider. The issue is that the patient has an unpleasant sensation regardless of whether there is an indirect or direct trauma. The proof is in the perception.

“In the past, we would say to a patient, in effect, ‘I don’t understand why you’re still in pain,’ or worse, ‘You really shouldn’t still be in pain now,'” said Weider. “Now we ask ‘What can we do to stop the pain?'”

What changed, he said, is the education doctors have received in pain management.

“Pain medicine has grown quite a bit,” said Sadik. In the future, he hopes, doctors will be able not only to understand their patients’ chronic pain, but to reliably alleviate it as well.

Amy Goodall named Youth Role Model, honored as Real Hero

Posted 3/26/07BAKERSFIELD – Pop stars seem to be topping the list of American teen idols these days. But there’s one teen who’s taken the top spot in Kern County for drawing attention to a disease that’s so rare, most doctors wrongly diagnose it and order drastic surgeries that were never needed.

Crowds of people, dozens of rock bands, and activities galore filled Veteran’s Hall over the weekend for “Rock out to knock out RSD,” a concert that sprang from one 16-year-old’s mission to spread the word about Reflex Sympathetic Dystrophy.

“It’s miserable,” said Todd True. “My foot swells up all the time. It freezes, and then it burns. Then it contracts uncontrollably. It’s misery.”

“Basically it’s a malfunction of the nervous system,” said Ashley Goodall, who was honored as this year’s Youth Role Model at the Real Hero Luncheon. “It misfires and tells the brain that part is being amputated or infected.”

For Goodall, that part of her arm and the symptoms that followed caused her doctor to misfire a diagnosis and order emergency surgery.

“I was in the hospital and they were getting ready to amputate my arm because they thought it was infected,” said Goodall.

Her arm was spared, but only because one doctor happened to come across a pamphlet on RSD. He called off the amputation at the literal last minute.

Goodall said she got lucky. But hundreds of others with RSD have not been as fortunate, and that’s why she’s made it her full-time job to get the same information that saved her arm into other people’s hands.

“It was a godsend,” said Ture. “I reached out to Ashley and I’m finding out these other places that she reached out to that I can now reach out to and it’s opening up doors for me and other people like me. It’s tremendous.”

Goodall also started a non-profit organization right out of her home. It’s called Rock Out to Knock Out RSD Inc. She did it to make sure she knew where all the money she raised was going.

Like walkers, wheelchairs, medicine for people that can’t afford it, and awareness of course,” she said.

Goodall hopes she and others with RSD will one day be able to lead normal lives.

In the meantime, she’s paving the way for an extraordinary change.

Goodall will be among those recognized at the American Red Cross Kern chapter Real Heroes recognition luncheon on March 30.

Sponsorship tables and tickets for the event are still available. Tables are $500 and tickets are $35. Tickets may be purchased at the American Red Cross at 239 18th Street from 9 a.m. to 4 p.m.

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Editor’s Note: The following isn’t in English, so I can’t read it… but it’s interesting that it notes a “spirochetal” origin for RSD. I’ve not hear that term before and wanted to post this to see if any of you had, what it means (if anything) and maybe pass along more information.

Titre du document / Document title

Auteur(s) / Author(s)

NEUMANN R. A. (1) ; ABERER E. ; STANEK G. ;

Affiliation(s) du ou des auteurs / Author(s) Affiliation(s)

(1) Univ. Vienna, dep. dermatology II, Vienna, AUTRICHE

Résumé / Abstract

Four female patients with Sudeck’s atrophy (SA) were evaluated at our department. Sera of all patients were investigated for antibodies against Borrelia burgdorferi. In all patients elevated IgG antibody titers and in one patient also elevated IgM titer were found. In one patient structures identical with B. burgdorferi could be detected on histological sections from the skin of the affected limb

Localisation / Location

INIST-CNRS, Cote INIST : 3851

Copyright 2006 INIST-CNRS. All rights reserved

Toute reproduction ou diffusion même partielle, par quelque procédé ou sur tout support que ce soit, ne pourra être faite sans l’accord préalable écrit de l’INIST-CNRS.No part of these records may be reproduced of distributed, in any form or by any means, without the prior written permission of INIST-CNRS.

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Lindsay’s Hope

(CBS 3)BOYERTOWN A once vibrant 22-year-old now spends her days and nights in constant pain, unable to eat and unable to walk.

However, through it all she still has a sparkle in her eye with hope possibly on the horizon.

“Pretty much everyday it’s just constant pain,” said Lindsay Spengler.

Lindsay was once a star athlete at her high school but Lindsay has been bedridden since 2002 after being diagnosed with two diseases; Reflex Sympathetic Dystrophy or RSD and Porphyria, combined they make her feel like her skin is burning.

“There are times when I look down just thinking it’s literally on fire,” said Lindsay.

RSD can remain dormant for years and is found after an injury and Lindsay’s case was discovered after she broke her thumb.

With RSD, the signal of pain from the nerves to the brain never stops and mixed with the disease Porphyria, which affects oxygen flow to organs, and the pain becomes a burning sensation.

“When she’s moving or someone touches her or there is a breeze, a drop of water, it sends her over the edge, it’s horrifically burning,” said Lindsay’s mother Sharon, adding, “She actually dreams about being on fire.”

Lindsay hasn’t been able to eat or walk for four years and she prays for the day she can do normal activities again.

Her prayers may be answered with word of an experimental treatment in Germany.

“We were pretty much at the end of our rope and I thought what if I have to live like this? That’s not an option,” said Lindsay.

Her family has to raise almost $200,000 for the procedure which will put her in a coma for up to seven days.

“A lot of patients return doing what they used to do so that would be awesome,” said Sharon.

“Wouldn’t it be great if I woke up and it was gone,” added Lindsay.

If you are interested in assisting Lindsay, you can visit New Hope For Lindsay for more information.

Living with pain: Woman copes with RSD

PRIOR LAKE — Bonnie Scherer of Prior Lake is no stranger to pain. She experiences pain equal to or exceeding that of childbirth on a daily basis.

The pain is so bad in her legs that she can’t wear pants. Even in subzero temperatures, people will see Bonnie in shorts.

She can’t work. She can’t sleep an eight-hour night. She can’t be up for more than two hours at a time. Every 15 minutes, she needs to sit down for two minutes to keep from going into a flare.

When times are bad, she sleeps above the covers.

“Anytime anything touches me, the bed sheets, pants, the dog’s tail, it is excruciating,” Bonnie said. “I can’t live life on any type of schedule. It’s hard to plan anything because you don’t know how you will feel.”

She doesn’t give into her pain. Bonnie perseveres through life and helps others live with reflex sympathetic dystrophy (RSD) through the nonprofit organization she and her husband Steve started: The Minnesota RSDS/CRPS Coalition.

RSD, also known as complex regional pain syndrome, is a chronic condition characterized by severe burning pain, pathological changes in bone and skin, excessive sweating, tissue swelling and extreme sensitivity to touch.

RSD comes on after a minor injury or trauma that the body faces, which develops into a chronic pain syndrome lasting long after the original injury, said Dr. L. Michael Espeland, an interventional pain management specialist at HealthEast Midway Pain Center in St. Paul.

Bonnie is not alone in her pain. Millions of people have RSD, and it is more commonly diagnosed as medical professionals learn more about the disease that began during the Civil War.

Bonnie developed RSD nine years ago, after she slipped on ice and sprained her ankle. Before being diagnosed with RSD, she saw a total of 17 doctors and had two surgeries on her ankle. She was told her pain was psychological. It was a sore ankle, and she had to learn to live with it.

She was told by three different neurologists that there was nothing that caused her symptoms.

After two years of differing medical opinions about the source of her pain, she was finally diagnosed with RSD.

RSD is difficult to diagnose because it’s very seldom that a patient shows all of the symptoms, Espeland said. It is a clinical diagnosis. There are no tests that give a definitive yes or no.

There is a need for a medical evaluation to diagnose RSD, said Nurse Practitioner Angie Bruker of Fairview Pain and Palliative Center. It’s a complex syndrome with a large group of symptoms. Medical professionals must look at the big picture and listen carefully to the patient. They can’t just review the history.

“It is something we don’t know a lot about. When there is a lack of understanding, there are problems treating it,” Bruker said.

“There are many different medical opinions,” Bonnie said. “Every doctor sees this disease differently. That is very validating, because as patients we see the difference in opinions a lot in the medical community. I have learned you can agree to disagree with your physician, but you still need to respect them.”

The therapies need to be combined with a cognitive-behavioral approach and physical therapy, Bruker said. It’s important to look at the overall functioning of the patient to enhance self-management, help them return to their roles in society and, when possible, decrease the pain.

“There is no cure for pain, so it is not always possible to decrease it,” she said.

The RSD pain scale is based on the patient’s level of pain, ranging from zero to 10, said LaVonne Dunn, a Brooklyn Center woman who has had RSD for 10 years.

“I have never talked to a person with RSD who has a pain level under five or six on a good day,” she said. “That’s where most of us want our pain to be.”

Bonnie lives her daily life at a seven or eight, she said. When first diagnosed, her pain level was a three or four.

A pain level of six or seven is incredible pain, Espeland said.

The pain is manageable in some cases through a number of pain medications, a spinal-cord stimulator that acts like a pacemaker for the nervous system, and electrical stimulation that passes through spinal fluid into the spine to block pain, replacing it with a more pleasant, warm, tingling feeling, Espeland said.

“RSD is very individualized. There are no absolutes with RSD,” said Dunn, a member of the coalition’s board. “People may experience similar symptoms or pain, but each individual responds to RSD differently.”

Bonnie has exhausted all of the options in an attempt to make her pain tolerable. She is on too many pain medications to count, has had sympathetic nerve system blocks, and is about to have a pain pump implanted with a medication derived from toxic properties of snails, in an attempt to touch the pain that morphine cannot.

In addition to medicine and treatment, Bonnie uses relaxation techniques such as guided imagery to calm her flares down.

“The longest time I have had without pain after a block was three hours,” Bonnie said. “I was in heaven. I had no pain. I didn’t know what that was like. This pain is my every day.”

The RSD coalition emblem is a candle called the light of hope, Bonnie said. “I’ve accepted that this will probably never go away, but a part of me has to believe there is a cure, especially when I see kids with it,” she said.

The pain Bonnie feels is not only physical, it is emotional.

Bonnie has been through severe depression, she said. “Its part of the process to get to the point of acceptance, but you can’t give up. Giving in doesn’t mean giving up.”

“It’s hard on the grandkids because they can’t just jump on grandma’s lap,” Steve said. “At first they don’t understand that. If they can’t physically see something wrong like a cast or a wheelchair, they don’t understand the pain.”

“The hardest part isn’t the pain,” Bonnie said. “It’s looking at Steve and my kids and my grandkids because they hurt, and I can see the pain in their eyes when they look at me and I can’t do something because the pain is severe or I fall down.”

Bonnie has become an advocate for people in pain. The coalition is a place for people with RSD to come together in the form of a support group.

“When the group started, everyone thought they were alone,” Steve said. “It makes group members so happy to meet other people who share the same experiences they do. The support has become so deep and the network is always there. It isn’t just two hours a week that they get to talk about their problems. All people have to do is pick up the phone or get on the Internet. They used to be alone, but now they have fiends who know how they feel.”

The coalition has become her family, Dunn said. “Following in Bonnie’s footsteps is something I can’t learn anywhere else. Bonnie and Steve mean a lot to me. They are very special people. They are always giving.”